Dew 187

Importance

1. MMR ­
2. Most undetected
3. 85% experience mood disturbances

Disorders

Pre-existing	Onset first in pregnancy
(depression, Anxiety (GAD, OCD, panic), psychotic- schizophrenia)	blues, depression, psychosistokophobia- fear of childbirthPP PTSD

Pregnancy is the riskiest period for psychosis

Pregnancy psychiatric disorders

	Postpartum blues	Postpartum depression	Post-partum psychosis
RF	Hx of depression Family dis-harmonyPMS, OCP induced mood changes	Prior depression, current depression/anxiety 50% chance ( may need to start Rx prophylactically)Poor family support, Adolescent, conflictTraumatic delivery, PTBCongenital malformation of child	Hx of psychotic disorder( shizoprenia, BAD) History of puerperal psychosis 50% risk Family history of puerperal psychosis First pregnancyRecent discontinuation of lithium or other mood stabilizers    Psychosis risk , hx BAD -25% , + F hx – 50%,+ compliance poor 70%),
frequency	Occur in 80% Dramatic hormonal change may cause	10-15%, similar to non-pregnant population	1-2 in 1000, rare
onset	2-5 days rapid onset Resolve at 2 weeks	PPD is not considered a separate diagnosis; “postpartum onset specifier” is used (DSM 5) MDD onset within 1 month   Most women had in AN	In DSM 5 its not recognized as a separate disorder Can be depression with psychosis BAD(highest risk) with psychosis or Shizoprenia   Within pregnancy within 1 month( most acute onset <2 weeks)
symptoms	Labile mood TearfulI rritable Anxiety Fatigue confusion	Screening: Edinborough postpartum epression scale >10 and PHQ-9   Similar to non pregnant depression-see below   Co morbid anxiety- about child , OCD symptoms , bipolar high	Depressive ,manic or mixed high and low mood   Labile mood Agitation Confusion Bizzare behavior Disorganization   Psychotic symptoms ( delutions ,hallucinations , thought disorganisation) related to child
risks	Progress to PP depression 25%	See below( suicide ,infanticide)Impair mother child bondingMarital stress	Loss of insight Impair mother child bonding
treatment	No drug RxSupportive treatmentLow dose benzodiasepines , Clonazepam, lorazepam for sleep	Exclude TFT, Aneamia, deliriumSupport: Involve and educate family and patient   MDT/AdmitMBU Psychotherapy /CBTMedical therapy ( sertraline) ECT low threshold( rapid resolution) BF advice	Psy emergency ( rapid deterioration, high devastating outcome) Acute disturbance : promethazine 25-75 IM, haloperidol IM 10mg     MDT/AdmitMBU- family member is there, undersupervision Support: Friendly env in ward/don’t scold mothers Involvement of family and other support systems for the patient and the newborn Psychoeducation for the patient and family members Exclude other causes: below Medical therapy ( sertraline, mood stabilizers, antipsychotics(:olanzapine, quetiapine, risperidone)- up to 1 year ( not 6/12)ECT low threshold( rapid response for agitated and risky mother, if not tolerate or improve to medicine)Sleep regulation: benzodiazepines Psychotherapy /CBT: after initial stabilisation BF advice
Follow up	Check resolution at 2 weeks   25% not resolve , chronic progress to chronic depression   Some may resolve spontaneously		Relapse 31%(2.9 times higher)

Depression diagnostic criteria MDD DSM 5

At least 2 weeks of

1. Low mood
2. Loss of interest and pleasure associated with at least 5
3. Appetite /weight change
4. Insomnia/hypersomnia
5. Psychomotor retardation/agitation
6. Decreased energy /fatigue
7. Worthlessness/guilt
8. Difficulty concentrating or making decisions
9. Recurrent thoughts of suicide or death

DD of psychosis

1. Drug toxicity withdrawal
2. SOL/CVA
3. Delirium
4. Organic pathology
5. Disoriented , no attention, sleep wake cycle change
6. Exclude organic before sending Psy
7. Infection
8. Thyroid disorders

Risks  of psychosis and depression

To self	infant	Long term
Suicide 5% Violent means( hanging, jumping)Elevated up to 1 year   Negative effect on family	Infanticide-4% BF establishment Decreased mother infant attachment	Mother Depression(MDD) Bipolar Baby Delayed motor development ADHD,Conduct disorder Depression, anxiety Medical illness

Drugs

Mood stabilisers and anti psychotics

class	Can use	preferred
Anti depressant	SSRI,SNRI	Sertraline, Fluoxetine safe, 20mg ,morning
Anti psychotic	Olanzepine ,respiridone	Olanzepine
Mood stabiliser	Valproate, mood stabilisers	Valproate,CBZ
Benzodiazepine	clonazepam

	AN	BF
Li	X ( ebstein anomaly, TSH,RFT) Unless essential	X 50% in BM ( hypotonia,poor sucking,sedation,slow growth)( monitor TSH,RFT) give Formula	Stop gradually 4 weeks If used increase during ANDecrease during PP
Lamotrigine	safe
valproate	x	safe	Ude CBZ
CBZ	Ok ( spina bifida, renal anomaly) Give FA
clozapine	x
antipsychotics	PTL,LBW,EPS,Withdrawal,cardiac defects, delayed neuro development

• Lithium X( AN-unless essential, BF-X or FF)

Lithium to be stopped gradually over 4 weeks

• Lamotrigine safe
• Valproate CBZ( AN-X, BF-can)
• Clozapine -X

NICE recommendations

 

Pre Preg care

1. Screen all for Psy disease, FHx
2. Discuss risks
   1. Mother, fetus, disease, drugs effects, parenting, child
3. MDT
4. Optimize mother Psy condition/ DM /HT
5. contraception
6. Change drugs

AN care and PP care

1. Screen all for Psy disease, FHx
2. Discuss risks
   1. Mother ,fetus , disease, drugs effects, parenting, child
3. MDT- R/V psy plan to records
4. Optimize
5. Change drugs
6. Add folic acid ( AED)
7. Anomaly scan (Li, Antipsychotics)
8. Drug level monitoring)
9. Growth scans
10. Labour: Pain relief
11. Contraception /sterilisation( capacity)
12. BF
13. High risk for PP depression/psychosis: treat if positive
14. Parenting
15. NN risks

1. Risk high after MC, SB

Risk

No Hx 1:1000

Sister or mother 3:1000

Hx of Psychosis 1:2 recurrence

BAD 1:2

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